Cost of hemodialysis after coverage by national health insurance in Japan: a sharing experience with Indonesian health reform system
122
Sawada and Kawahara.
Cost of hemodialysis under health reform system
Med J Indones, Vol. 23, No. 2,
May 2014
B ri e f Co mmuni cat i o n
Cost of hemodialysis after coverage by national health
insurance in Japan: a sharing experience with Indonesian
health reform system
Tokihiko Sawada, Hirohisa Kawahara
Kaikoukai Medical Foundation, Japan
Abstrak
Abstract
Sekitar 50 tahun lalu, Jepang membuat sistem asuransi
kesehatan yang mencakup seluruh warga negara, dan
memulai periode pertumbuhan ekonomi secara cepat,
sama dengan di Indonesia saat ini. Walaupun peningkatan
kondisi kesehatan berkontribusi terhadap perkembangan
Jepang, biaya kesehatan menjadi beban yang serius
di bidang ekomoni. Dalam laporan singkat ini, kami
meninjau konsep pengeluaran perawatan kesehatan di
Jepang, berfokus pada penyakit gagal ginjal stadium
akhir, untuk memberikan saran pada reformasi kesehatan
di Indonesia.
About 50 years ago, Japan established a health insurance
system covering the entire population, and started a period
of rapid economic growth, similar to what is happening
now in Indonesia. Although improvements in health
conditions deinitely contributed to the development
of modern Japan, the costs of medical care became a
serious burden on the economy. In this short report, we
review the concept of medical care expenditure in Japan,
focusing especially on end-stage renal disease, to provide
suggestions to medical reform in Indonesia.
Keywords: health reform system, hemodialysis
pISSN: 0853-1773 • eISSN: 2252-8083 • http://dx.doi.org/10.13181/mji.v23i2.652 • Med J Indones. 2014;23:122-4
Correspondence author: Tokihiko Sawada, tsawada@kaishou.or.jp
Indonesia is the world’s fourth most populous
nation with 240 million population. The population
is dominated by young people in which 55% of
its population being under the age of 30, and is
expected to grow 22% between 2010 and 2040. With
the growing population, Indonesia’s medical care
expenditure (MCE) is predicted to reach US$60.6
billion by 2018, showing an increase of 14.9% over
the 2012-2018 period.1
Indonesia is now reforming its national health
insurance system. Indonesia already has several
insurance schemes covering around 60% of the
population. These schemes include the poor and nearpoor (Jamkesmas), public sector workers (Askes),
private-sector employees (Jamsostek) and the military
(Taspen). However, around 86 million low-income
people still have no access to healthcare services. The
Indonesian government is restructuring the present
system to provide universal health care for all citizens
by January 1, 2014.The new health care system will
combine existing public insurance schemes, and extend
them to cover all Indonesians without health insurance.
End-stage renal disease (ESRD) is a life-threatening
condition that requires some form of renal replacement
therapy, such as hemodialysis (HD), peritoneal dialysis,
or kidney transplantation. Because ESRD is caused
by many morbidities, including diabetes mellitus,
and hypertension, it is anticipated that the number of
patients with ESRD in Indonesia will increase.2,3
HD, the most commonly used renal replacement
therapy, requires a huge budget in order to maintain
the life of patients, and its cost is a serious burden on
MCE in other countries. In Japan, the governmentbased health insurance system (GBHI) was established
in 1962. HD was covered by the GBHI in 1967, and in
Copyright @ 2014 Authors. This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0
International License (http://creativecommons.org/licenses/by-nc-sa/4.0/), which permits unrestricted non-commercial use, distribution, and reproduction in
any medium, provided the original author and source are properly cited.
http://mji.ui.ac.id
Med J Indones, Vol. 23, No. 2,
May 2014
Sawada and Kawahara.
Cost of hemodialysis under health reform system
1968 only 215 patients were maintained on HD in the
whole of Japan. Coverage of HD by the GBHI allowed
patients with ESRD to undergo HD, and the number of
patients receiving it grew with time, becoming 27,048
in 1978, 88,534 in 1988, 185,322 in 1998, 283,421 in
2008, and 304,592 in 2012 (Figure 1A).4
maintained on HD, and the cost of HD. The cost of
HD was calculated on the basis the minimum cost
of US$ 4000/person/month. For example, in 2010,
there were 298,252 patients on HD, and thus cost
was US$ 14.3 billion/year.
As shown in these igures, expenditure for HD
increased year by year after coverage of HD was
included in the GBHI. The cost of HD increased
faster in relation to Gross Domestic Product (GDP)
and the national budget. Figure 2A and 2B shows
the ratio of MCE to GDP and the national budget,
respectively. Despite sustained governmental efforts
to reduce the MCE, the ratio of MCE relative to both
GDP and the national budget has been increasing.
National growth is inevitably accompanied by much
faster expansion of the MCE.
The GBHI, covering all citizens of Japan, continued
to expand after its introduction, costing US$18.0
billion in 1968, 64.8 billion in 1975, 160.2 billion
in 1985, 269.6 billion in 1995, 331.2 billion in 2005,
and 374.2 billion in 2010 (Figure 1B).5
Because all the costs of medical care are determined
and changed by the Japanese government every two
years, the cost of HD has frequently been changed.
Grossly, between 1970-1990, HD cost about US$
5,000-6,000/person/month,
and
4000/person/
6
month thereafter. Because no data are available
for expenditure speciically for HD between 1968
and the present, in Figure 1C, the costs have been
calculated from the number of ESRD patients
300000
400
(A)
A
123
Furthermore, HD expense has grown faster than the
MCE. Figure 3A,B, and C shows the ratio of expense
for HD relative to GDP, the national budget, and the
MCE, respectively. The increase in HD expense has
20
B
(B)
(C)
200000
100000
USD (billion)
USD (billion)
Patients
C
300
200
100
15
10
5
0
0
1970
1980
1990
Year
2000
1960 1970 1980 1990 2000 2010
Year
2010
1970
1980
1990
Year
2000
2010
Figure 1. Changes in the number of patients with ESRD maintained on hemodialysis (A), changes of medical expenditure (B), and
changes of the cost of hemodialysis (C)
(A)
(A)
(B)
(B)
10
50
8
40
MCE/Budget (%)
MCE/GDP (%)
(A)
6
4
2
30
20
10
0
0
1970
1980
1990
Year
2000
2010
1970
1980
1990
2000
2010
Year
Figure 2. Changes in the cost of MCE relative to Gross Domestic Product (GDP) (A) and the nationalbudget (B)
http://mji.ui.ac.id
124
Med J Indones, Vol. 23, No. 2,
May 2014
(B)
(C)
0.4
2.0
5
1.5
4
0.3
0.2
0.1
HD/MCE (%)
(A)
HD/Budget (%)
HD/GDP (%)
(A)
Sawada and Kawahara.
Cost of hemodialysis under health reform system
1.0
0.5
3
2
1
0
0.0
1990 2000 2010
1970 1980 1990 2000 2010
1970 1980 1990 2000 2010
Year
Year
Year
Figure 3. Changes in the cost of HD relative to GDP (A), the national budget (B), and medical care expenditure (MCE) (C).The cost of
(C)
HD increased faster than that of GDP, the national budget, and MCE
0.0
1970
(C)
1980
been faster than that of national growth and even
faster than that of the MCE.
Japan experienced a period of rapid growth in 19601990, and this period also showed a rapid increase
of patients with ESRD and requiring HD. HD needs
inancial support from the health care system because
of its nature. Patients need to undergo HD for 4-5
hours, 2-3 times a week, regularly. This has led to an
increased number of ESRD patients requiring HD,
placing a serious burden on MCE in Japan.
Current medical care reform in Indonesia will
deinitely contribute to improving the health
condition of Indonesian citizens, and will
strengthen its integrity as a nation-state. HD should
deinitely be covered by the future insurance system
in Indonesia. To achieve this ultimate purpose,
Indonesians should learn from the Japanese
experience. Strategies for maximizing the beneits
of GBHI and for minimizing the cost for HD is
mandatory.
http://mji.ui.ac.id
Conlict of interest
The authors hereby afirm that there is no conlict of
interest in this study.
REFERENCES
1.
2.
3.
4.
5.
6.
The Jakarta Post. com [Internet]. Indonesia’s healthcare
spending set to expand. [updated 2013 March 30]. Available
from:
http://www.thejakartapost.com/news/2013/03/30/
indonesia-s-healthcare-spending-set-expand.html
Prodjosudjadi W, Suhardjono A. End-stage renal disease
in Indonesia: treatment development. Ethn Dis. 2009; 19(1
Suppl 1): S1-33-6.
Soewondo P, Ferrario A, Tahapary DL. Challenges in
diabetes management in Indonesia: a literature review.
Global Health.2013;9:63.
The Japanese Society for Dialysis Therapy [Internet].
Available from: http://docs.jsdt.or.jp/overview/pdf2013/
p003.pdf
Ministry of Health, Labour and Welfare. Available from: http://
www.mhlw.go.jp/toukei/saikin/hw/k-iryohi/10/dl/toukei.pdf
Yasuhiro Tsuji. Available From: http://www.yasuhiro-tsuji.
jp/data/touseki.pdf
Sawada and Kawahara.
Cost of hemodialysis under health reform system
Med J Indones, Vol. 23, No. 2,
May 2014
B ri e f Co mmuni cat i o n
Cost of hemodialysis after coverage by national health
insurance in Japan: a sharing experience with Indonesian
health reform system
Tokihiko Sawada, Hirohisa Kawahara
Kaikoukai Medical Foundation, Japan
Abstrak
Abstract
Sekitar 50 tahun lalu, Jepang membuat sistem asuransi
kesehatan yang mencakup seluruh warga negara, dan
memulai periode pertumbuhan ekonomi secara cepat,
sama dengan di Indonesia saat ini. Walaupun peningkatan
kondisi kesehatan berkontribusi terhadap perkembangan
Jepang, biaya kesehatan menjadi beban yang serius
di bidang ekomoni. Dalam laporan singkat ini, kami
meninjau konsep pengeluaran perawatan kesehatan di
Jepang, berfokus pada penyakit gagal ginjal stadium
akhir, untuk memberikan saran pada reformasi kesehatan
di Indonesia.
About 50 years ago, Japan established a health insurance
system covering the entire population, and started a period
of rapid economic growth, similar to what is happening
now in Indonesia. Although improvements in health
conditions deinitely contributed to the development
of modern Japan, the costs of medical care became a
serious burden on the economy. In this short report, we
review the concept of medical care expenditure in Japan,
focusing especially on end-stage renal disease, to provide
suggestions to medical reform in Indonesia.
Keywords: health reform system, hemodialysis
pISSN: 0853-1773 • eISSN: 2252-8083 • http://dx.doi.org/10.13181/mji.v23i2.652 • Med J Indones. 2014;23:122-4
Correspondence author: Tokihiko Sawada, tsawada@kaishou.or.jp
Indonesia is the world’s fourth most populous
nation with 240 million population. The population
is dominated by young people in which 55% of
its population being under the age of 30, and is
expected to grow 22% between 2010 and 2040. With
the growing population, Indonesia’s medical care
expenditure (MCE) is predicted to reach US$60.6
billion by 2018, showing an increase of 14.9% over
the 2012-2018 period.1
Indonesia is now reforming its national health
insurance system. Indonesia already has several
insurance schemes covering around 60% of the
population. These schemes include the poor and nearpoor (Jamkesmas), public sector workers (Askes),
private-sector employees (Jamsostek) and the military
(Taspen). However, around 86 million low-income
people still have no access to healthcare services. The
Indonesian government is restructuring the present
system to provide universal health care for all citizens
by January 1, 2014.The new health care system will
combine existing public insurance schemes, and extend
them to cover all Indonesians without health insurance.
End-stage renal disease (ESRD) is a life-threatening
condition that requires some form of renal replacement
therapy, such as hemodialysis (HD), peritoneal dialysis,
or kidney transplantation. Because ESRD is caused
by many morbidities, including diabetes mellitus,
and hypertension, it is anticipated that the number of
patients with ESRD in Indonesia will increase.2,3
HD, the most commonly used renal replacement
therapy, requires a huge budget in order to maintain
the life of patients, and its cost is a serious burden on
MCE in other countries. In Japan, the governmentbased health insurance system (GBHI) was established
in 1962. HD was covered by the GBHI in 1967, and in
Copyright @ 2014 Authors. This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0
International License (http://creativecommons.org/licenses/by-nc-sa/4.0/), which permits unrestricted non-commercial use, distribution, and reproduction in
any medium, provided the original author and source are properly cited.
http://mji.ui.ac.id
Med J Indones, Vol. 23, No. 2,
May 2014
Sawada and Kawahara.
Cost of hemodialysis under health reform system
1968 only 215 patients were maintained on HD in the
whole of Japan. Coverage of HD by the GBHI allowed
patients with ESRD to undergo HD, and the number of
patients receiving it grew with time, becoming 27,048
in 1978, 88,534 in 1988, 185,322 in 1998, 283,421 in
2008, and 304,592 in 2012 (Figure 1A).4
maintained on HD, and the cost of HD. The cost of
HD was calculated on the basis the minimum cost
of US$ 4000/person/month. For example, in 2010,
there were 298,252 patients on HD, and thus cost
was US$ 14.3 billion/year.
As shown in these igures, expenditure for HD
increased year by year after coverage of HD was
included in the GBHI. The cost of HD increased
faster in relation to Gross Domestic Product (GDP)
and the national budget. Figure 2A and 2B shows
the ratio of MCE to GDP and the national budget,
respectively. Despite sustained governmental efforts
to reduce the MCE, the ratio of MCE relative to both
GDP and the national budget has been increasing.
National growth is inevitably accompanied by much
faster expansion of the MCE.
The GBHI, covering all citizens of Japan, continued
to expand after its introduction, costing US$18.0
billion in 1968, 64.8 billion in 1975, 160.2 billion
in 1985, 269.6 billion in 1995, 331.2 billion in 2005,
and 374.2 billion in 2010 (Figure 1B).5
Because all the costs of medical care are determined
and changed by the Japanese government every two
years, the cost of HD has frequently been changed.
Grossly, between 1970-1990, HD cost about US$
5,000-6,000/person/month,
and
4000/person/
6
month thereafter. Because no data are available
for expenditure speciically for HD between 1968
and the present, in Figure 1C, the costs have been
calculated from the number of ESRD patients
300000
400
(A)
A
123
Furthermore, HD expense has grown faster than the
MCE. Figure 3A,B, and C shows the ratio of expense
for HD relative to GDP, the national budget, and the
MCE, respectively. The increase in HD expense has
20
B
(B)
(C)
200000
100000
USD (billion)
USD (billion)
Patients
C
300
200
100
15
10
5
0
0
1970
1980
1990
Year
2000
1960 1970 1980 1990 2000 2010
Year
2010
1970
1980
1990
Year
2000
2010
Figure 1. Changes in the number of patients with ESRD maintained on hemodialysis (A), changes of medical expenditure (B), and
changes of the cost of hemodialysis (C)
(A)
(A)
(B)
(B)
10
50
8
40
MCE/Budget (%)
MCE/GDP (%)
(A)
6
4
2
30
20
10
0
0
1970
1980
1990
Year
2000
2010
1970
1980
1990
2000
2010
Year
Figure 2. Changes in the cost of MCE relative to Gross Domestic Product (GDP) (A) and the nationalbudget (B)
http://mji.ui.ac.id
124
Med J Indones, Vol. 23, No. 2,
May 2014
(B)
(C)
0.4
2.0
5
1.5
4
0.3
0.2
0.1
HD/MCE (%)
(A)
HD/Budget (%)
HD/GDP (%)
(A)
Sawada and Kawahara.
Cost of hemodialysis under health reform system
1.0
0.5
3
2
1
0
0.0
1990 2000 2010
1970 1980 1990 2000 2010
1970 1980 1990 2000 2010
Year
Year
Year
Figure 3. Changes in the cost of HD relative to GDP (A), the national budget (B), and medical care expenditure (MCE) (C).The cost of
(C)
HD increased faster than that of GDP, the national budget, and MCE
0.0
1970
(C)
1980
been faster than that of national growth and even
faster than that of the MCE.
Japan experienced a period of rapid growth in 19601990, and this period also showed a rapid increase
of patients with ESRD and requiring HD. HD needs
inancial support from the health care system because
of its nature. Patients need to undergo HD for 4-5
hours, 2-3 times a week, regularly. This has led to an
increased number of ESRD patients requiring HD,
placing a serious burden on MCE in Japan.
Current medical care reform in Indonesia will
deinitely contribute to improving the health
condition of Indonesian citizens, and will
strengthen its integrity as a nation-state. HD should
deinitely be covered by the future insurance system
in Indonesia. To achieve this ultimate purpose,
Indonesians should learn from the Japanese
experience. Strategies for maximizing the beneits
of GBHI and for minimizing the cost for HD is
mandatory.
http://mji.ui.ac.id
Conlict of interest
The authors hereby afirm that there is no conlict of
interest in this study.
REFERENCES
1.
2.
3.
4.
5.
6.
The Jakarta Post. com [Internet]. Indonesia’s healthcare
spending set to expand. [updated 2013 March 30]. Available
from:
http://www.thejakartapost.com/news/2013/03/30/
indonesia-s-healthcare-spending-set-expand.html
Prodjosudjadi W, Suhardjono A. End-stage renal disease
in Indonesia: treatment development. Ethn Dis. 2009; 19(1
Suppl 1): S1-33-6.
Soewondo P, Ferrario A, Tahapary DL. Challenges in
diabetes management in Indonesia: a literature review.
Global Health.2013;9:63.
The Japanese Society for Dialysis Therapy [Internet].
Available from: http://docs.jsdt.or.jp/overview/pdf2013/
p003.pdf
Ministry of Health, Labour and Welfare. Available from: http://
www.mhlw.go.jp/toukei/saikin/hw/k-iryohi/10/dl/toukei.pdf
Yasuhiro Tsuji. Available From: http://www.yasuhiro-tsuji.
jp/data/touseki.pdf